aetiology? 2022
- Cigarette smoking - most common
- Occupational exposures; Air pollution, indoor burning of biomass fuels, and occupational exposure to dusts + chemical agents.
A1 antitrypsin deficiency - risk factor not a cause.
symptoms?
cough - morning; becomes constasnt with progression
sputum - may change if infection present
SOB - w/exercise. at rest if progressed
signs?
WHeeze - on expiration. more common in exacerbations
Distant breath soudns
Hyper resonance on percusison
Barrel chest
if very progressed;
1. Signs of hypercapnia; cyanosis, asterixis, tachypnoea,
- Cardiac; hepatosplenomegaly, distended neck venis, HJ reflux, lower extremity swelling (signs of cor pulmonale and pulmonary htn)
signs with an exacerbation?
Coarse crackles
Wheeze
Fever etc
why may clubbing occur in COPD?
COPD itself does not cause clubbing. The presence of clubbing should alert the clinician to a related condition (e.g., lung cancer or bronchiectasis).
Investigations?
- Spirometry:
A. FEV1/FVC ratio: obstructive picture <0.7*
B. FEV1: severity of copd
- * post bronchodilator value - to diagnose COPD (there is not a complete reversal)
- GOLD grouping - COPD Assessment Test (CAT)
- the higher the number the higher the symptom burden - FBC - may show polycythaemia (haematocrit >55%), anaemia, and leucocytosis,
esoniphil count important in mx
- ABG, sats, - if unwell/exacerbation or low fev1
- CXR - hyperinflation, fflatten diaphragm (not diagnostic)
- ECG - right heart signs; if cor pulmonale
- a1 antitrypsin - positive family history and atypical COPD cases (young patients and non-smokers)
GOLD grouping for COPD?
GOLD 1 - FEV1 > 80. mild
GOLD 2 - to 50. mod
GOLD 3 - to 30. sev
GOLD 4 - below 30. v sev
to remember 3+5 = 8
testing in copd?
airflow limitation; GOLD, FEV
symptom burden; CAT, mmRC scale
Non pharmalogical rx in COPD?
- Stop smoking
- Vaccines flu, strep pneumonia
- Pulmonary rehab; if GOLD 2-4
- Oxygen supplement:
PaCO₂ >50 mmHg and/or PaO₂ of <60 mmHg - respiratory insufficiency - NIV
if hypercapnia or acute exacerbation
facts in copd mx
LAMA > LABA in exacerbations
combination therspies better than sole
remember LAMA + ICS therapy is NEVER done
ICS used when there are exacerbations.
Pharma mx of COPD? 2022 - clarify with Dr SAM
- 0-1 Exacerbations each year no hospitalisation:
GOLD A: SABA or LABA (salbutamol or salmeterol)
GOLD B: LABA or LAMA (salmeterol or tiotroprium)
- 2+ Exacerbations each year + hospitalisation:
GOLD C: LAMA (tiotropium)
GOLD D:
LAMA or
LAMA + LABA - if more sympotatic (CAT score)
ICS + LABA - if more exacerbations (high EOSINOPHIL COUNT)
How do we tailor follow up management in COPD?
It heavily depends on whether issue is with SYMPTOMS (SOB) orrr EXACERBATIONS following initial therapy
in general, for SOB, ICS will not be given as only helps in exacerbations
and for exacerbations, 3 remaining options will be to add ICS, Azithromycin or Roflumilast (PD4 inhbitors)
how do we FU mx COPD pts?
SOB/symptoms;
Switch from Mono to dual therapy (LABA + LAMA)
Exacerbations:
High eosinophil (>300) - Add ICS
Low eosinophil - Azithromycin (if former smoker), (if not) Roflumilast
when do you refer patients for assessment for long term oxygen therapy LTOT?
Hypoxaemia (not for SOB)
Sats < 92%
GOLD D or FEV1 < 30
FEV1 30-40
Cyanosis, polycythaemia, High JVP, Oedema
when councilling patients about oxygen therapy, what must they be warned about?
DO NOT SMOKE - risk of explosion
other details;
wont need to wear nasal cannula all day, depends on severity of hypoxia. may just a few hours a day.
O2 helps to improve liffespan if disease is severe.
when do we refer for respiratoy opinion?
Haemoptysis - under 2WW Less than 40 yo - a1antitrypsin Frequent infections - ?bronchiectasis Signs of Cor pulmonale Diagnostic uncertainty
Need for;
O2 therapy, nebuliser, Long term Oral steroids
complications of COPD?
Local;
Pneumonia
lung cancer
Lung collapse
-- Systemic; polycythaemia Anaemia Depression Right heat failure /cor pulmonale - result of chronic hypoxaemia
